Radiotherapy Clinic Research Articles

Outcomes of patients receiving urgent palliative radiotherapy for advanced lung cancer: an observational study

BackgroundThere is considerable variability in the management of patients with advanced lung cancer referred for palliative radiotherapy owing to uncertainties in prognosis and the benefit of treatment. This study presents the outcomes of patients seen in the Fast Track Lung Clinic, an urgent access palliative radiotherapy clinic, and aims to identify factors associated with treatment response and survival.MethodsConsecutive patients with advanced lung cancer seen in the Fast Track Lung Clinic between January 2014 and July 2020 were included. Patients who underwent radiotherapy were contacted beginning 30 days after radiotherapy to evaluate treatment response. Cluster bootstraps were used to compute confidence intervals for treatment response rate. Prognostic factors for treatment response and overall survival were identified using multivariable generalized estimating equations and Cox regression models, respectively.ResultsA total of 558 patients were included, of whom 459 (82.3%) consented to palliative radiotherapy for 1053 indications. The overall treatment response rate was 70.0% (95% CI, 65.8-74.2) for indications with follow-up (70.8%). Higher response rates were observed in patients with better ECOG performance status (OR per point, 0.71; 95% CI, 0.55-0.93; P=0.01) and EGFR-mutant non-small cell lung cancer (OR vs wild-type, 2.46; 95% CI, 1.35-4.51; P=0.003), whereas patients treated for neurological symptoms had lower response rates (OR, 0.27; 95% CI, 0.16-0.45; P<0.001). There was no difference in response rate between patients who died within 30 days of starting radiotherapy and those who survived longer (OR, 0.83; 95% CI, 0.42-1.67; P=0.61). Age; ECOG performance status; smoking history; pathology; EGFR or ALK mutation status; and the presence of liver, adrenal, or brain metastases were associated with overall survival.ConclusionsPalliative radiotherapy was effective for patients with advanced lung cancer, although response rates varied by patient characteristics and treatment indication. This study identified prognostic factors for radiotherapy response and overall survival that can inform treatment decisions in this population.

Automated confidence estimation in deep learning auto-segmentation for brain organs at risk on MRI for radiotherapy.

We have built a novel AI-driven QA method called AutoConfidence (ACo), to estimate segmentation confidence on a per-voxel basis without gold standard segmentations, enabling robust, efficient review of automated segmentation (AS). We have demonstrated this method in brain OAR AS on MRI, using internal and external (third-party) AS models. Thirty-two retrospectives, MRI planned, glioma cases were randomly selected from a local clinical cohort for ACo training. A generator was trained adversarialy to produce internal autosegmentations (IAS) with a discriminator to estimate voxel-wise IAS uncertainty, given the input MRI. Confidence maps for each proposed segmentation were produced for operator use in AS editing and were compared with "difference to gold-standard" error maps. Nine cases were used for testing ACo performance on IAS and validation with two external deep learning segmentation model predictions [external model with low-quality AS (EM-LQ) and external model with high-quality AS (EM-HQ)]. Matthew's correlation coefficient (MCC), false-positive rate (FPR), false-negative rate (FNR), and visual assessment were used for evaluation. Edge removal and geometric distance corrections were applied to achieve more useful and clinically relevant confidence maps and performance metrics. ACo showed generally excellent performance on both internal and external segmentations, across all OARs (except lenses). MCC was higher on IAS and low-quality external segmentations (EM-LQ) than high-quality ones (EM-HQ). On IAS and EM-LQ, average MCC (excluding lenses) varied from 0.6 to 0.9, while average FPR and FNR were ≤0.13 and ≤0.21, respectively. For EM-HQ, average MCC varied from 0.4 to 0.8, while average FPR and FNR were ≤0.37 and ≤0.22, respectively. ACo was a reliable predictor of uncertainty and errors on AS generated both internally and externally, demonstrating its potential as an independent, reference-free QA tool, which could help operators deliver robust, efficient autosegmentation in the radiotherapy clinic.

88 Clinical Implementation of Same Day Volumetric Modulated Arc Therapy in a Rapid Access Palliative Radiotherapy Clinic Using an Automated Planning Script

88 Clinical Implementation of Same Day Volumetric Modulated Arc Therapy in a Rapid Access Palliative Radiotherapy Clinic Using an Automated Planning Script

A script-enabled interactive checklist document for efficient management of electronic devices in a busy multimodality radiotherapy clinic.

Develop an efficient, interactive, and instructive checklist document for the management of implanted electronic medical devices in a multimodality radiotherapy clinic. The built-in scripting and interactivity of a popular commercial word processor was used to develop an interactive document that changes the information presented to the user based on drop-down selections. The interactivity and scripting were compatible with the radiation oncology information system (ROIS) which allows the document to be accessible by all team members and serve as a permanent record in a patient's electronic chart. The final interactive document, which was clinically deployed after beta testing with a group consisting of nurses and medical physicists, presents information and action plans to the user based on multiple departmental medical device decision trees that are specific to the combination of device, treatment modality, rhythm-pacing dependence for cardiac devices, and distance from the device to the treatment volume. A script-enabled interactive document was developed for a busy multimodality clinic, condensing multiple comprehensive departmental guidelines spanning multiple device types and treatment modalities into a single interactive checklist accessible within the ROIS. Given the wide accessibility of the commercial word processor, this approach could be adopted by other clinics to streamline their own respective workflows.

Robust optimization of a radiotherapy pretreatment preparation workflow

Objective. Increasing cancer incidence, staff shortage and high burnout rate among radiation oncologists, medical physicists and radiation technicians are putting many departments under strain. Operations research (OR) tools could optimize radiotherapy processes, however, clinical implementation of OR-tools in radiotherapy is scarce since most investigated optimization methods lack robustness against patient-to-patient variation in duration of tasks. By combining OR-tools, a method was developed that optimized deployment of radiotherapy resources by generating robust pretreatment preparation schedules that balance the expected average patient preparation time (F mean) with the risk of working overtime (RoO). The method was evaluated for various settings of an one-stop shop (OSS) outpatient clinic for palliative radiotherapy. Approach. The OSS at our institute sees, scans and treats 3–5 patients within one day. The OSS pretreatment preparation workflow consists of a fixed sequence of tasks, which was manually optimized for radiation oncologist and CT availability. To find more optimal sequences, with shorter F mean and lower RoO, a genetic algorithm was developed which regards these sequences as DNA-strands. The genetic algorithm applied natural selection principles to produce new sequences. A decoder translated sequences to schedules to find the conflicting fitness parameters F mean and RoO. For every generation, fitness of sequences was determined by the distance to the estimated Pareto front of F mean and RoO. Experiments were run in various OSS-settings. Main results. According to our approach, the expected F mean of the current clinical schedule could be reduced with 37%, without increasing RoO. Additional experiments provided insights in trade-offs between F mean, RoO, working shift length, number of patients treated on a single day and staff composition. Significance. Our approach demonstrated that OR-tools could optimize radiotherapy resources by robust pretreatment workflow scheduling. The results strongly support further exploration of scheduling optimization for treatment preparation also outside a one-stop shop or radiotherapy setting.

Multiprofessional dedicated breast cancer adjuvant radiotherapy clinic: improved productivity and a streamlined patient pathway

Multiprofessional dedicated breast cancer adjuvant radiotherapy clinic: improved productivity and a streamlined patient pathway

Better, faster, sooner: introducing a rapid access palliative radiotherapy clinic to south-east Wales

Better, faster, sooner: introducing a rapid access palliative radiotherapy clinic to south-east Wales

Robotic Stereotactic Radiotherapy for Intracranial Meningiomas-An Opportunity for Radiation Dose De-Escalation.

To evaluate the possibility of dose de-escalation, with consideration of the efficacy and safety of robotic stereotactic CyberKnife radiotherapy in patients diagnosed with intracranial meningiomas. The study group consisted of 172 patients (42 men and 130 women) treated in III Radiotherapy and Chemotherapy Clinic of Maria Sklodowska-Curie National Research Institute of Oncology in Gliwice between January 2011 and July 2018. The qualification for dose de-escalation was based on MRI (magnetic resonance imaging) features: largest tumor diameter less than 5 cm, well-defined tumor margins, no edema, and no brain infiltration. The age of patients was 21-79 years (median 59 years) at diagnosis and 24-80 years (median 62 years) at radiotherapy. Sixty-seven patients (Group A) were irradiated after initial surgery. Histopathological findings were meningioma grade WHO 1 in 51 and WHO 2 in 16 cases. Group B (105 patients) had no prior surgery and the diagnosis was based on the typical features of meningioma on MRI. All patients qualified for the robotic stereotactic CyberKnife radiotherapy, and the total dose received was 18 Gy in three fractions to reference isodose 78-92%. Follow-up period was 18 to 124 months (median 67.5 months). Five- and eight-year progression free survival was 90.3% and 89.4%, respectively. Two patients died during the follow-up period. Progression of tumor after radiotherapy was registered in 16 cases. Four patients required surgery due to progressive disease, and three of them were progression free during further follow-up. Twelve patients received a second course of robotic radiotherapy, 11 of them had stable disease, and one patient showed further tumor growth but died of heart failure. Crude progression free survival after both primary and secondary treatment was 98.8%. Radiotherapy was well-tolerated: acute toxicity grade 1/2 (EORTC-RTOG scale) was seen in 10.5% of patients. We did not observe any late effects of radiotherapy. Stereotactic CyberKnife radiotherapy with total dose of 18 Gy delivered in three fractions showed comparable efficacy to treatment schedules with higher doses. This could support the idea of dose de-escalation in the treatment of intracranial meningiomas.

Polymer gel dosimetry for experimental verification of conformal small animal irradiation at a preclinical research platform

In translational research, there is a need for preclinical studies of high quality that corresponds to the conformal dose distributions conventionally delivered to humans in the modern radiotherapy clinic. To facilitate this need, novel preclinical systems consist of preclinical radiation platforms and small animal treatment planning systems. However, small-field dosimetry is challenging and requires dosimeters with high spatial resolution. In this study we demonstrate the feasibility of experimentally validating the dose distribution in small fields at a preclinical X-ray research platform using a polymer gel dosimeter and MRI-readout.

Standardizing LT Chest Wall Radiotherapy Treatment Planning in a Low- or Middle- Income Country Radiotherapy Clinic Using Knowledge Based Planning

Radiotherapy departments in low- or middle-income countries (LMICs) tend to lag behind introducing emerging technologies like intensity-modulated radiotherapy (IMRT). IMRT has become the standard of care in high-income countries (HIC) due to reduced toxicity and improved outcomes in a wide variety of cancers. The purpose of this work is showing the results of left Chest-Wall knowledge-based planning (KBP) standardization and implementation in a LMIC setting. A Halcyon Linac was installed at our clinic in Guatemala in 2019 and currently used to treat ∼90 IMRT patients daily. The standardization of IMRT procedures has been difficult for complex sites like chest-wall. The steps for standardization included: AAPM TG-263 nomenclature implementation, and planning workflows within the TPS, creation of optimization structures, and plan quality evaluation following RTOG1005 protocol hypofractionation arm. 25 plans were created manually achieving all RTOG1005 protocol constraints. The statistics were analyzed trough the model analytics tool provided by KPB manufacturer. The results show that more plans are needed to improve the KBP model. This initial model was used to create a standardized clinical protocol in the TPS in order to continue adding plans to the KBP model database. This approach ensures that we obtain consistent plan quality and standardize our planning. The manual planning objectives achieved: CONCLUSION: The experience using the TPS to standardize our treatment planning process achieved good consistency in our planning objectives. This approach will help create KBP models according to our own clinic-specific requirements. Future work will be made to compare our LMIC KBP models with those made at a HIC academic radiotherapy center.

Clinical implementation of standardized neurocognitive assessment before and after radiation to the brain.

Radiotherapy induced impairment of cognitive function can lead to a reduced quality of life. The aim of this study was to describe the implementation and compliance of standardized neurocognitive assessment. In addition, the first results of cognitive changes for patients receiving a radiation dose to the brain are described. Patients that received radiation dose to the brain (neuro, head and neck and prophylactic cranial irradiation between April-2019 and Dec-2021 were included. Three neuro cognitive tests were performed a verbal learning and memory test, the Hopkins Verbal Learning Test; a verbal fluency test, the Controlled Oral Word Association Test and a speed and cognitive flexibility test, the Trail Making Test A&B. Tests were performed before the start of radiation, 6months (6m) and 1year (1y) after irradiation. The Reliable Change Index (RCI) between baseline and follow-up was calculated using reference data from literature. 644 patients performed the neurocognitive tests at baseline, 346 at 6months and 205 at 1y after RT, with compliance rates of 90.4%, 85.6%, and 75.3%, respectively. Reasons for non-compliance were: 1. Patient did not attend appointment (49%), 2.Patient was unable to perform the test due to illness (12%), 3. Patient refused the test (8 %), 4. Various causes, (31%). A semi-automated analysis was developed to evaluate the test results. In total, 26% of patients showed a significant decline in at least one of variables at 1y and 11% on at least 2 variables at 1y. However, an increase in cognitive performance was observed in 49% (≥1 variable) and 22% (≥2 variables). Standardized neurocognitive testing within the radiotherapy clinic was successfully implemented, with a high patient compliance. A semi-automatic method to evaluate cognitive changes after treatment was defined. Data collection is ongoing, long term follow-up (up to 5years after treatment) and dose-effect analysis will be performed.

Long-term results of breast cancer patients who received IOERT as boost during BCS: A single-institution retrospective analysis.

Intraoperative electron radiotherapy (IOERT) applied as boost to the tumor bed during breast conserving surgery is advantageous in terms of local recurrence in breast cancer patients. In addition, it has other advantages over the adjuvant boost RT such as no risk of tumor bed change, ease of sequencing radiotherapy chemotherapy, and reduced workload of the radiotherapy clinic. This study aimed to evaluate the long-term results of our patients who were treated with this method in our institution and are still being followed up. One hundred and three patients enrolled in this study received IOERT equivalent to 10 Gy as boost during BCS and were subsequently given adjuvant WBI according to the biological subtype of the tumor systemic therapy. These patients were analyzed using their files and hospital records. Patients were evaluated for overall survival, local recurrence, distant metastasis, and cosmetic outcome (using LENT-SOMA scale). Median age was 53,5 (27-74), mean follow-up time was 75 (48-106) months. Mean pathological tumor size was 18 mm (4-30), 90 of the patients had invasive ductal carcinoma, eight of them were lobular and five of them had mixed histological structure. Ninety-three of the patients presented histological grade II, 15 grade III; 74 patients were luminal A-like, 15 luminal B-like, eight HER2 positive and six triple negative breast cancer. According to the LENT-SOMA scale, 35 had grade 0, 42 each had grade I, 23 had grade II, and two had grade III. All patients underwent whole breast irradiation after surgery, 81 received chemotherapy and 90 endocrine therapy. There was one local recurrence, distant recurrence was seen in four patients and one patient died of non-breast cancer causes. Overall survival was %99, and event free survival %96. IOERT for breast cancer treatment during BCS is a safe option with low chronic toxicity and the cosmetic outcome gets better over time.

Determining the quality control frequency of an MR-linac using risk matrix (RM) analysis.

Quality control (QC) is performed routinely through professional guidelines. However, the recommended QC frequency may not be optimal among different institutional settings. Here we propose a novel method for determining the optimal QC frequency using risk matrix (RM) analysis. A newly installed Magnetic Resonance linac (MR-linac) was chosen as the testing platform and six routine QC items were investigated. Failures of these QC items can adversely affect treatment outcome for the patient. Accordingly, each QC item with its assigned frequency forms a unique failure mode (FM). Using FM-effect analysis (FMEA), the severity (S), occurrence (O), and detection (D) of each FM was obtained. Next, S and D based on RM was used to determine the appropriate QC frequency. Finally, the performance of new frequency for each QC item was evaluated using the metric E=O/D. One new QC frequency was the same as the old frequency, two new QC frequencies were less than the old ones, and three new QC frequencies were higher than the old ones. For six QC items, E values at the new frequencies were not less than their values at the old frequencies. This indicates that the risk of machine failure is reduced at the new QC frequencies. The application of RM analysis provides a useful tool for determining the optimal frequencies for routine linac QC. This study demonstrated that linac QC can be performed in a way that maintains high performance of the treatment machine in a radiotherapy clinic.

Reimagining Education in Global Radiotherapy: The Experiences and Contribution of Rayos Contra Cancer

Technology advancements ushered in a new era of how we reimagine our human interaction, with videoconferencing becoming commonplace in educational, professional, and social settings. These tools became the new paradigm in online/virtual education for all institutions around the world. Particularly in global health, where the traditional norm for support relied on traveling and onsite visits, we face a ripe opportunity for innovation. From 2019 to present, Rayos Contra Cancer has conducted remote operations by organizing the efforts of volunteer educators and moderators who are radiotherapy professionals or trainees from across the United States and other parts of the world. On average, each program consists of 17 virtual sessions. The hour-long sessions are conducted over Zoom and include didactics, question-and-answer dialogue with participants, and sample cases. The educators are seasoned and accomplished radiation oncologists, physicists, dosimetrists, and radiation therapists who teach single or multiple topics in a program. Participants are radiotherapy professionals or trainees affiliated with a radiotherapy clinic in a low- and middle-income country. The number of participant clinics ranged from 2 to 120 per program. Our combined programs have resulted in over 2,000 unique participants spanning approximately 500 unique centers in 54 countries with the support of over 200 unique educators and moderators from centers in 18 countries. When the world shut down, we were forced to reimagine how we approached global health education. Our data show tremendous growth year to year and from one curriculum to another. The feedback from our participants demonstrates that our approach is an effective way to engage practitioners in radiotherapy centers with fewer resources.

COVID-19 and Radiotherapy

Background: The SARS-CoV-2 pandemic has also had a profound impact on cancer treatment delivery and organization. Oncology clinics have developed a number of procedures and used formulas related to radiotherapy doses to continue their activities. Aims and Objectives: We explored the impact of SARS-CoV-2 pandemy on the personnel and cancer patients undergoing radiotherapy in a radiotherapy department during the first year. Materials and Methods: 845 patients were treated over the course of a year, 195 of whom consented to participate in the study. The Elekta Mozoiq system and radiotherapy cards were evaluated, and the time intervals between the treatments during the radiotherapy were recorded. Biologically Effective Dose losses were calculated in the radiotherapy dose due to the interruption to treatment, and necessary calculations were made for the delivery of the initially planned dose. Results: The mean age of the patients was 59 years (range 19-78). There were 110 male (56.4%) and 85 female (43.5%) participants. The treatment of 4.6% (9 patients) of the patients was discontinued because of SARS-CoV-2 infection during radiotherapy. The greatest added fraction for a patient with prostate cancer was three while the lowest was one for a patient with lung cancer, based on the TDF calculation. During this period, 16% of the staff was infected with COVID-19. Conclusion: This study demonstrates the effect of the COVID-19 pandemy on patients and personnel in a radiotherapy clinic, and its management during one year.

GI factors, potential to predict prostate motion during radiotherapy; a scoping review

PurposeA scoping literature review was conducted to identify gastrointestinal (GI) factors most likely to influence prostate motion during radiotherapy. We proffer that patient specific measurement of these GI factors could predict motion uncertainty during radiotherapy, facilitating personalised care by optimising treatment technique e.g., daily adaption or via bespoke patient pre-habilitation and preparation. MethodsThe scoping review was undertaken as per JBI guidelines. Searches were conducted across four databases: Ovid Medline®, EMBASE, CINAHL and EBSCO discovery. Articles written in English from 2010-present were included. Those pertaining to paediatrics, biological women exclusively, infectious and post-treatment GI morbidity and diet were excluded.Common GI factors impacting men were identified and related symptoms, incidence and measurement tools examined. Prevalence among persons with prostate cancer was explored and suitable assessment tools discussed. ResultsA preliminary search identified four prominent GI-factors: mental health, co-morbidity and medication, physical activity, and pelvic floor disorder. The scoping search found 3644 articles; 1646 were removed as duplicates. A further 1249 were excluded after title and abstract screening, 162 remained subsequent to full text review: 42 mental health, 53 co-morbidity and medication, 39 physical activity and 28 pelvic floor disorder.Six GI factors prevalent in the prostate cancer population and estimated most likely to influence prostate motion were identified: depression, anxiety, diabetes, obesity, low physical activity, and pelvic floor disorder. Reliable, quick, and easy to use tools are available to quantify these factors. ConclusionA comprehensive GI factor assessment package suitable to implement into the radiotherapy clinic has been created. Unveiling these GI factors upfront will guide improved personalisation of radiotherapy.

Patient and therapeutic radiographer experiences of comfort during the radiotherapy pathway: A qualitative study

IntroductionThere is little research regarding the experiences of patient comfort and how it is best managed in radiotherapy. The aim of this study was to explore the experiences of patient and therapeutic radiographer views of comfort during radiotherapy. MethodsThis qualitative study involved semi-structured interviews, with cancer patients (n = 25) and therapeutic radiographers (n = 25), conducted between January–July 2019. Patients were recruited from one radiotherapy clinic and therapeutic radiographers were recruited from across the United Kingdom via specialist interest groups and social media. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was used to analyse the data separately between both groups and shared themes were identified. ResultsFour themes were identified of which two themes were shared among both the patients and therapeutic radiographer. Emotional Health was a shared theme highlighting experiences such as stress, vulnerability and privacy. The second shared theme, Positioning and Immobilisation Experiences, concerned how patients’ experience being physically positioned and using immobilisation for accurate radiotherapy. The theme Information and Communication Experience was derived from patients highlighting concerns over sharing and provision of information and ways of communication. The last theme, Environmental Experience, emerged from the patient interviews and related to the first impressions of the radiotherapy environment such as reception or treatment rooms and how this effects the overall feelings of comfort. ConclusionThis qualitative study has provided the shared voice of patients and therapeutic radiographers and their experiences of comfort during radiotherapy. These shared experiences emphasise the importance of considering comfort holistically and not just from a physical context. This information can be used by therapeutic radiographers to better understand their patients experiences and needs to provide better comfort during radiotherapy to improve patients’ outcomes. Implications for practiceThe clinical implications of our study can encourage Therapeutic Radiographers to provide holistic care for their patients throughout the pathway and specifically to comfort patients while they are having treatment. In the short term this could be via simple adaptions to practice while in the long term, research is needed to develop comfort interventions for patients receiving radiotherapy.

Radiotherapy and palliative care outpatient clinic: a new healthcare integrated model in Italy

BackgroundOn the basis of substantial evidence demonstrate that palliative care combined with standard care improves patient, caregiver, and society outcomes, we have developed a new healthcare model called radiotherapy and palliative care (RaP) outpatient clinic were a radiation oncologist and a palliative care physician make a joint evaluation of advanced cancer patients.MethodsWe performed a monocentric observational cohort study on advanced cancer patients referred for evaluation at the RaP outpatient clinic. Measures of quality of care were carried out.ResultsBetween April 2016 and April 2018, 287 joint evaluations were performed and 260 patients were evaluated. The primary tumor was lung in 31.9% of cases. One hundred fifty (52.3%) evaluations resulted in an indication for palliative radiotherapy treatment. In 57.6% of cases was used a single dose fraction of radiotherapy (8 Gy). All the irradiated cohort completed the palliative radiotherapy treatment. An 8% of irradiated patients received the palliative radiotherapy treatment in the last 30 days of life. A total of 80% of RaP patients received palliative care assistance until the end of life.ConclusionAt the first descriptive analysis, the radiotherapy and palliative care model seem to respond to the need of multidisciplinary approach in order to obtain an improvement on quality of care for advanced cancer patients.

Comparison of 3D-Conformal Planning Using Partially Wide Tangents and Direct Photon/Electron Portals for Breast Radiotherapy with Internal Mammary Nodes Inclusion: A Dosimetric Analysis

Background: Internal mammary lymph nodes (IMNs) are a potential site of metastasis for breast cancer. Targeting IMNs as part of a comprehensive regional nodal irradiation comes at the cost of higher unwanted doses to critical nearby organs at risk. Thus, the efficacy and safety of different radiotherapy techniques for the coverage of this area remain elusive. Objectives: We present a dosimetric comparison between partially wide tangents (PWT) and direct photon/electron (P/E) portals in terms of target volume coverage and normal tissue sparing. Methods: Patients with left-sided breast cancer, who were referred to our clinic for post-lumpectomy or post-mastectomy radiotherapy, underwent computed tomography (CT) simulation. The left breast and IMNs, heart, lung, right breast, and esophagus were contoured. Dosimetric comparisons were based on dose-volume histograms (DVHs) generated for all of the aforementioned organs. A subgroup analysis was also performed based on patients’ type of surgical treatment. Results: A total of 30 patients (10 with breast conserving surgery and 20 with modified radical mastectomy) were included. The P/E plan provided a higher coverage of the left breast (P-value of CTV V105%: &lt; 0.001) and IMNs with a P-value of 0.087 regarding the mean dose received by IMNs, and also less volume of the heart (P-value of Heart V30Gy: 0.021), and lungs (P-value of Lung V20Gy: 0.003) were irradiated. However, these advantages came at the cost of a higher dose to the esophagus and right breast and more hotspots compared to the PWT technique. Conclusions: The P/E technique had advantages regarding target volume coverage and toxicity regardless of the type of surgery. Based on the results of this study, overall, the P/E portal is superior to the PWT for radiotherapy of breast cancer with internal mammary node inclusion. However, the appropriate treatment plan should be decided on a case-by-case basis.

Prospects for fungal bioremediation of unburied waste packages from the Goiânia radiological accident.

Goiânia, the Goiás State capital, starred in 1987, where one of the largest radiological accidents in the world happened. A teletherapy machine was subtracted from a derelict radiotherapy clinic and disassembled by scavengers who distributed fragments of the 50 TBq 137CsCl source among relatives and acquaintances, enchanted by the blue shine of the substance. During the 15days before the accident was acknowledged, contaminated recycling materials were delivered to recycling factories in four cities in the state of São Paulo, Brazil, in the form of recycling paper bales. The contaminated bales were spotted, collected, and stored in fifty 1.6 m3 steel boxes at the interim storage facility of the Nuclear and Energy Research Institute (IPEN). In 2017, a check of the content was performed in a few boxes and the presence of high moisture content was observed even though the bales were dry when conditioned and the packages were kept sealed since then. The main objective of this work was to report the fungi found in the radioactive waste after they evolved for 30years in isolation inside the waste boxes and their role in the decay of the waste. Examination of the microbiome showed the presence of nematodes and fungal communities. The fungi species isolated were Aspergillus quadricinctus, Fusarium oxysporum, Lecanicillium coprophilumi, Scedosporium boydii, Scytalidium lignicola, Xenoacremonium recifei, and Pleurostoma richardsiae. These microorganisms showed a significant capacity to digest cellulose in our trials, which could be one of the ways they survive in such a harsh environment, reducing the volume of radioactive paper waste. These metabolic abilities give us a future perspective of using these fungi in biotechnology to remediate radioactively contaminated materials, particularly cellulose-based waste.